GW1-2022-01915_Well Construction - GW1_20220224

WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Jonathan Karnionka 14.WATER ZONES s
FROM I To DESCRIPTION
Well Contractor Name 200 ft• 230 ft•
3465-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells ?EL ifa livable
FROM TO DIAMETER THICKNESS MATERIAL
Bill's Well Drilling Co. ft. ft. in.
Company Name 16.INNER CASING OR TUBING eothernW closed400Dl
2020-1362 FROM To DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +1 ft• 125 ft• 6-1/8 i°• SDR21 PVC
List all applicable wel/permits(i.e.County,State, Variance,Injection,etc.)
fL I ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
[]Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 50 ft. bentonite poured
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardy ess,soil/rock type,grain size,eft.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 10 ft. Orange Clay
6-15-21 10 1" 35 ft. Orange sand&large gravel
4.Date Well(s)Completed: Well ID# 35 ft. 45 ft. Orange clay
5a.Well Location: 45 It- 61 ft. Gray Sand&clay w/wood
Benjamin Stout Real Estate Services,Inc.
61 ft• 113 ft• Mixed Clay
Facility/Owner Name Facility ID#(if applicable)
113 ft- 230 ft. Gray&Red Rock
9082 Hawkins Rd, Linden, NC 28356 ft. ft.
Physical Address,City,and Zip
21.REMARKS
Cumberland 0573-16-1721 C F,
County Parcel Identification No.(PIN) - '
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification: FEB 2 4 202?
(if well field,one lat/long is sufficient)
N W w ?�f sK�e1�i
Signature of Certified Well Contractor tk,
!I� tl-t-J��i`i�i'�r�i"'rll�orl.u�"S.'G �e 1
6.Is(are)the well(s): [OPermanent or ❑Temporary By signing this form,I hereby certify that the we/l(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC,02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or IZINo copy ofihis record has been provided to the ivell owner.
lfthis is a repair,fill out known well construction information and explain the nature of the
repair under k21 rennarks section or on the back of this fornn. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For nultiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 230 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use^+„ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6"&5.75" (in) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
Air& Mud Rotary 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 20+ Method of test: blowing 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: HTH Amount: 1 Cup well construction to the county health department of the county where
constructed. i
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013